It is surprising that the nipple shield, the use of which we had seen
decline rapidly from the 1970’s and before, would once again be thought in the
2000’s as an appropriate treatment to cure many breastfeeding problems? It was
generally thought to be a mistake to use nipple shields as their use resulted
in babies seeming to be stuck on these gadgets. With time, the mother’s milk
production would usually decrease if a mother used a nipple shield. Some
studies will suggest that there is not a decrease; if one compares milk
extraction on a nipple shield to a poorly latched baby, sure, there may be no
decrease. The point is to get a baby well latched. We believe a nipple shield
does not allow for this. Unfortunately, it is still true in our opinion that it
is often not best practise to use a nipple shield and it is the considered
opinion of our clinic and institute that nipple shields need hardly ever, if
ever, be used.
What are nipple shields?
A nipple shield is different from a breast shield or shell. The breast
shell is not used while feeding the baby, but rather in between feedings, and
its purpose is to make the nipple more prominent, so that the baby will take
the breast better, or, to protect the nipple from contact with the mother’s
bra, particularly when the nipple has trauma. Whether the shell actually
succeeds in this purpose is debatable, but a breast shell is probably harmless;
a nipple shield is not harmless.
Nipple shields are flexible artificial nipples put over the mothers
nipple and areola. They are made of silicone nowadays and come in various
diameters and sizes. They are used generally for the following reasons:
1.
The baby will not take the breast.
2.
The mother has sore nipples.
3.
The baby is born prematurely.
4.
The baby needs to “learn how to suck”.
Nipple shields are not, in fact, the answer to these problems. They
give the illusion that the problems have been dealt with, but in fact, the
problems have not been dealt with at all. The illusion that things are now
going well leads to mothers not getting help early and making fixing the
problems more difficult as time goes by. Let’s look at these questions more
closely.
1. The baby will not take the breast.
A nipple shield is not usually the answer. In fact, a baby who sucks
at the breast through a nipple shield is not latched on to the breast; he is
latched on to the nipple shield. Does this matter? Yes, because a poor latch is
still a poor latch and baby on a nipple shield has, at best, a poor latch. This
means the baby will depend on the mother’s having milk ejection reflexes
(letdown reflexes) in order to get milk. If the mother’s milk production is
abundant, then the baby actually may gain weight well. Even then, however, we
believe that it is problematic to use the nipple shield (see below).
Many mothers have a good milk supply but not what one would call an
abundant milk supply. In that case it is very possible that the baby will not
gain weight adequately with a nipple shield. Furthermore, as mentioned above,
when a baby feeds through a nipple shield, the milk supply can even decrease
(see the information sheet Slow Weight Gain after Early Good Weight Gain).
Even worse, if the milk supply decreases, it becomes more difficult to get the
baby to take the breast without using a nipple shield.
Even if some justification can be found for using a nipple shield,
starting one before the “milk comes” in is, in our opinion, not best practise.
So many babies who do not latch on in the first few days, will latch on without
trouble, even easily, when the mother’s milk “comes in”, especially if the
mother gets good help. If the mother believes that the nipple shield has dealt
with her problem, she may not get help until it is too late. Here is just one
email (identifying information deleted) of hundreds we could have included:
“My baby was born on xxx weighing 2.5 kg (5lb 8oz). I started using a
breast shield when the baby was a few days old because my baby would not latch
on; everything seemed to go okay, but somewhere around 3 weeks I began to
notice she didn’t seem to be sucking properly and by her one month check up
she’d only gained an ounce.”
So what now? After a month feeding on the nipple shield, it may be
extremely difficult to get the baby to take the breast directly especially if
the slow weight gain was due to the milk supply decreasing rather than the baby
not getting milk well because of the nipple shield (both are, in fact,
possible). The mother may have been asked to supplement. The mother needed a
lot of support.
We believe it is better that a mother express her milk and give it to
the baby by cup (or, if absolutely necessary, by bottle) rather than use a
nipple shield. At least expressing milk will usually maintain the milk supply.
See the information sheets When the Baby Does Not Yet Latch, Finger
& Cup Feeding and Expressing Milk.
2. The mother has sore nipples
Using a nipple shield for sore nipples has the same problems as using
it for a baby who will not latch on. Milk supply may decrease and the baby may
not want to take the breast directly again. Furthermore, a nipple shield is not
a good way to treat sore nipples, oftentimes it will make the problem worse and
cause more trauma. True, I have heard from some mothers that using the nipple
shield helped them get past the pain and they were able to get the baby to take
the breast again without pain; this is not always the case and there are better
ways of dealing with sore nipples (prevention being the best of all). See the
information sheets When Latching, Sore Nipples, The All Purpose
Nipple Ointment, Candida Protocol as well as the video clips.
3. The baby is born prematurely.
If the baby is not restricted to starting breastfeeding at 34 weeks
gestation (as in most of special care units or neonatal intensive care units in
North America and Western Europe), if the mother is helped get the best latch
possible and shown how to know a baby is getting milk, then nipple shields will
hardly ever be necessary for the premature baby. See the information sheet Premature
Baby.
4. The baby needs to learn how to suck
A baby learns to suck and suck well by breastfeeding. If a baby “sucks
better” on a nipple shield it’s only because the baby is not latching on to the
breast. A baby who latches on and gets milk will suck just fine. The problem is
that the baby is not latching on well and using a nipple shield does not teach
a baby now to do that.
Nipple Shields April 2009©
Written by Jack Newman MD, FRPC, and Edith Kernerman IBCLC, 2009©
All of our information sheets may be copied and
distributed without further permission
on the condition that it is not used in ANY context
that violates the
WHO International Code on the Marketing of
Breastmilk Substitutes (1981)
and subsequent World Health Assembly resolutions.